Tag Archives: Switzerland

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A“was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

“In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

Three more case reports, three different stories. In each case gender dysphoria is related to the eating disorder, but in each case the relationship is different.

In the first case a trans woman (born male) had an eating disorder in adolescence. After sex reassignment surgery, her eating disorder returned.

In the second case, a trans woman developed an eating disorder when she decided to come out and live as a woman. At the time of the case report, she was on hormones and awaiting surgery.

In the third case, a trans man (born female) who had been living as a man had had long periods of being underweight and not menstruating. He denied dieting or caring about his weight, but he was very dissatisfied with his body. He was purging. Unfortunately, he also had alcoholism and had developed liver disease; he was therefore unable to take hormones.

There is no clear relationship here between transition and eating disorders. In one case, transition made the eating disorder worse. In another deciding to transition was linked to the eating disorder, but taking hormones did not cure the eating disorder.

These are, of course, case studies of only three individuals, so we can not draw any conclusions from them. As with other case studies, it seems that each individual is different.

However, for one of the patients, her eating disorder seems to have started when she decided to live as a woman, like the patients in this study, this study and this one. For some trans women, at least eating disorders are linked to gender dysphoria.

In the case of the trans man, his eating disorder went untreated for many years, like the trans man in this case study.

These cases are from a Swiss hospital program for gender identity disorder.

Case 1 – Trans Woman’s Eating Disorder Returns After Surgery

In early childhood, the patient was gender non-conforming and felt that she was a girl. As a teenager, she felt a deep aversion to her genitals and the development of secondary sex characteristics. She avoided swimming because she was ashamed of her body.

In adolescence, the patient was dissatisfied with her body and dieted until she was underweight (BMI=16.9 kg/m²). She held the weight for several months.

She cross-dressed “moderately” starting at age 20. She was distressed during her compulsory military service. She lived with a woman and later married, but was not very interested in sex. Her marriage only lasted 1½ years and after the divorce she decided to transition.

At age 36 she began taking hormones. Sixteen months later she had sex reassignment surgery and her eating disorder returned:

It is not clear why the eating disorder would return after she had surgery. By the time she had surgery, she had been living as a woman for a few years and taking hormones for over a year.*

Did the change in hormones after surgery affect her eating disorder? After surgery, her testosterone levels would have been lower than most cis women’s and low testosterone is linked to eating disorders in both men and women. In addition, for some women, higher levels of estrogen are linked to eating disorders.

Alternatively, did the complications of her surgery trigger a desire to control her body? Or had she been focused on changing her body with hormones and surgery and then when she was done, she focused on her weight? Or was her eating disorder a sign of persistent body dissatisfaction no matter what she did?

Case 2 – Trans Woman Develops Eating Disorder When She Transitions

The second patient had identified as a girl and felt like an outcast since early childhood. Her teachers did not allow her to play with girls’ toys. She started secretly cross-dressing in elementary school. She was suicidal at age 10 and said she wanted to live as a girl.

The physical changes of puberty were very distressing to the patient. She was attracted to men, but did not have any sexual relationships because she was afraid and because she did not want people to think that she was gay.

The patient attempted suicide at age 20 because of her gender dysphoria. After the suicide attempt, she got psychiatric therapy and decided to come out as a woman. She started to dress as a woman in public.

Deciding to transition caused this patient to develop an eating disorder as she tried to change her shape. Socially transitioning and taking hormones did not cure her eating disorder.

Case 3 – Trans Man with a Long-standing Eating Disorder

This is a very depressing case.

The patient preferred boys’ games growing up and felt he belonged with the boys. At age 6 he was sent to the school counselor because he refused to play with girls. His breasts caused him distress, but he did not bind them or self-mutilate. He got his period at age 14, but had secondary amenorrhea (no period for six months or more) for many years.

He was attracted to females and had had only female partners. His partners accepted him as male.

He had been living “in the male role” for over 20 years, but had never had any medical treatments for his gender dysphoria. He had refused to take estrogen for his amenorrhea, however.

The patient was underweight when he came to the gender identity clinic and he had been very underweight in the past.

The authors could not treat her with hormones, however, because of “severe liver disease and the psychic instability and alcohol dependence.”

Although the patient denied it, it might be that he was keeping his weight down in order to avoid having periods.

Social transition did not help this patient with his eating disorder. We can’t know whether or not hormones would have helped him since he was medically unable to take them.

Gender dysphoria is clearly linked to the eating disorders of the two trans women and possibly linked to the trans man’s eating disorder. Transitioning did not cure the trans women’s eating disorders, however. In one case surgery led to the symptoms returning after many years.

*In Switzerland at the time of these case studies, trans people had to live as their preferred gender for at least a year before they could get hormones. After at least 6 to 12 months on hormones, they were eligible for surgery.

** The authors of this study refer to the patients by their birth sex unless they have fully and legally transitioned.

This is a case study of a 35-year-old woman who had Asperger syndrome and gender dysphoria. The authors discuss her psychological profile in detail.

They believe that her gender dysphoria developed because she had Asperger’s syndrome.

They say:

“…we noticed over-developed logical thinking and accentuation of logical-abstract abilities, as well as an imbalance of low emotionality and a high level of instrumental, non-emotional attributes including activity, lack of emotionality and perseverance. These characteristics are generally associated with masculinity and may have led to a subjective consciousness in our patient of being male. In this regard, primary cognition and perception in AS (Asperger’s syndrome) may be interpreted as masculine attributed and pave the way to the development of the female-to-male GID (gender identity disorder). The adaptation of the male gender identity, from early life on, possibly enabled the patient to better integrate the lack of emotionality and the accentuated logical-abstract abilities. The extremely high level of masculinity can be interpreted as an additional compensatory effort to accentuate the biologically absent male side.

Taking this into account, we believe that over the years, our patient has developed GID as a consequence of adopting male emotional and cognitive traits due to AS. Following this argument, GID in this patient could be regarded as a sequel to AS.”

Although the authors think the gender dysphoria was caused by Asperger’s, they believe that because there is no treatment for Asperger’s, gender dysphoria in Asperger’s should still be treated as a “primary GID.”

The patient did well with cross-gender living and the clinic treated her for GID following international standards.

They also refer to the “well-known exaggerated masculinity in female-to-male GID patients.”

Because of the above, the authors hypothesized that gender dysphoria could develop in a woman with Asperger’s because Asperger’s syndrome is associated with behaviors we consider masculine. Their theory fits the person in this case study. It might make sense for other trans men.

The problem with this theory, however, is that it does not explain trans women with Asperger’s.

Asperger’s syndrome is more common than would be expected among boys and men with gender dysphoria, too. There is no logical way to understand why men with extra masculine brains and behaviors would believe that they were women and want to transition.

This way of looking at the connection between Asperger’s syndrome and gender dysphoria might lead therapists to assume that a woman with Asperger’s syndrome was correct when she said she had gender dysphoria, but a man with Asperger’s syndrome was confused.

It is, of course, possible that trans men and trans women with Asperger’s syndrome want to transition for different reasons.

On the other hand, it seems simpler to think that whatever links Aspergers and gender dysphoria in men is the same thing as what links them in women.

More About the Patient from the Study:

The patient was not diagnosed with Asperger’s in her childhood, although she had some inconsistencies in her social relationships and was very interested in details and structured and geometric entities. At age 33 she asked to be examined for Aspergers; she was diagnosed with Aspergers in 2001.

The patient remembered always wanting to be a boy. She chose male playmates (although she seems to have mostly not had playmates), liked football, and acted like a tomboy. She “insisted on being a boy and refused girl’s clothing.” She had heterosexual platonic partnerships that did not work out due to her lack of social skills.

At age 34 the patient sought treatment for gender dysphoria. She was diagnosed with GID by two of the authors of the study in 2003.

The study discusses all the tests they gave her and the results. Her intelligence scores were in the upper average range with no discrepancies between verbal and performance measures. She did poorly on a test of executive function; apparently this is common in people with Asperger’s syndrome.

For a test called the Personal Attitudes Questionnaire (PAQ) she scored as less feminine and more masculine than male controls. According to the authors, “This fits the profile of patients with Asperger syndrome and is consistent with female-to-male GID.”

She also had a low score on a test of attractivity/self-confidence; the authors say this is consistent with the “body image distortions described by patients with gender identity syndrome.”